Provider Demographics
NPI:1164069472
Name:SOUTHWELL AMBULATORY INC
Entity Type:Organization
Organization Name:SOUTHWELL AMBULATORY INC
Other - Org Name:SOUTHWELL GASTROENTEROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-353-3397
Mailing Address - Street 1:907 E 18TH STREET
Mailing Address - Street 2:SUITE 400
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3684
Mailing Address - Country:US
Mailing Address - Phone:229-353-3422
Mailing Address - Fax:229-353-6060
Practice Address - Street 1:410 CONNELL ROAD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1407
Practice Address - Country:US
Practice Address - Phone:229-244-1570
Practice Address - Fax:229-299-4291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-05
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty